A nurse practitioner-led effort to reduce 30-day heart failure readmissions

Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission.

The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks.

To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used.

A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented.

The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%.

Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.